Reality is, the question itself is incorrectly asked! A consultant surgeon or other medical professional doesn’t set his/her own fees. Instead the fees payable are designated by the private medical insurance company with whom the patient is insured.
Take ANY surgical episode (or consultation for that matter) and you’ll discover the fee payable by one insurance company will differ between that set by a second insurance company even though the same episode takes place. So it’s the insurance company that sets the fee and the fee can differ between them.
Taking the above example further using a fictitious CCSD code of XX4321, insurance company A may set the fee at £100, insurance company B set the fee at £125 and insurance company C at £150. Across them there is a difference of £50.
The problem arises when the consultant makes a mistake and bills insurance company C with the £100 set by insurance company A, and immediately looses £50.
That said, if insurance company A is billed insurance Company C’s £150, immediately the consultant is shortfalled. The suggested (and WRONG) solution is to pass the shortfall to the patient. By all means do so up to the point, insurance company A realise what is being done. Keep doing it and your recognition will be at serious risk!
Yet consistently many consultants complain that the fee is too low (which it probably is) but don’t realise it is because they are charging £100 when the insurance company concerned will happily pay £150.
How do you manage such a situation and set your fees?
You don’t. You employ an outsource company to make sure you are invoicing the right fee in the first place!
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Since private medical insurance first began, the number one route by a patient to a consultant surgeon has been the patient’s GP. Most time the patient will follow the GP recommendation but what if they don’t?
What does the private patient look for in a consultant surgeon?
Ease of access is the most often quoted reason a patient chooses a specific consultant. This is a logical progression from why the patient has private medical insurance originally – because he/she wishes immediate access to a consultant surgeon. Allied to this is the location of the consultant surgeon.
But how does the patient narrow down the search if there are many consultants to a geographic area all of whom are easily accessible?
The patient will look for recommendation from friends and colleagues who have been patients of the consultant. They almost certainly will check the internet for the consultant’s website. That said, it is not unusual for the patient to check the website AFTER making an appointment. Further still there is a gender divide with almost 90% of female patients looking at a consultant surgeon’s website but only 50% of male patients.
However, the story doesn’t end there. Empirical evidence confirms the first impression of a patient when he/she contacts a Private Medical Practitioner is a big influence on whether the consultant is actually engaged.
It is perhaps significant that one MHM client insists the telephone is answered within 3 rings and enjoys an extremely busy initial patient schedule. A second uses an answering machine service but consequently has a much lower number of initial patient consultations.
So, the patient is looking for ease of access to the consultant, a good reputation and to be managed by the Practice extremely professionally.
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The argument if a private patient should be allowed at an NHS location is not the debate here. For one thing, the debate would require a substantially longer blog article than space will allow!
This blog instead seeks to answer the patient’s question of “ Can I be seen privately on the NHS?” And the answer is YES.
There are many, many NHS facilities at which private patients may be seen.
Known as PPU (Private Patient Units), these units in the NHS offer a greater choice to those patients wishing to be seen privately. What is interesting is that the prices for an NHS Private Patient are often very competitive when compared with a private hospital.
Do not assume though that only self-funders can be seen at a PPU. In reality, most PPU are recognised by the Private Insurance Companies and often will arrange for their account to be sent direct to the insurance company.
However some policies – see an earlier blog – will restrict access to certain hospitals of the insurance company’s choice.
But in answer to the real life question asked by a patient of an MHM consultant surgeon client, YES a patient can be seen privately at an NHS location.
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Every so often I take a phone call from a self-funding patient or an insured patient who requires a receipt for their payment. They need a receipt so they can claim the money back from their health cash plan provider.
For example, patient visits a physiotherapist, pays for their treatment, MHM issue a receipt on behalf of the Physiotherapist. The patient claims the fee back from their Health Cash plan provider. Alternatively, the patient is insured but outpatient appointments are not covered under their policy.
Health Cash Plans are designed to ease the financial burden of having such regular health checks. Dentistry or a visit to the opticians for example. They are NOT the same as a private medical insurance policy.
So why are they relevant to the consultant surgeon?
Well on some occasions it has indeed transpired that the patient’s private medical insurance cover does NOT include outpatient appointments. Therefore the patient has paid for them but requires a receipt so they may claim the cost from the Health Cash Plan provider,
Thus it is important to understand what a Health Cash Plan is and how it may compliment a private medical insurance policy.
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It is dangerous for a privately insured patient to assume his/her insurance covers everything. Very often it does not and this impacts on the consultant surgeon.
Private medical insurance is designed for short-term injuries or illness i.e. an injury that suddenly happens and in most cases treated/cured relatively quickly. For example: a broken hand can be treated relatively quickly whereas a diabetic problem may not.
Consider it this way. Private medical insurance is in place to cover elective non-urgent operations such as knee replacement. A heart attack will be treated at an NHS level. In any event, if the condition was known before the policy was taken out, it will not be covered. Further, it does NOT follow however that if the injury is short-term and treatable under private medical insurance cover, all parts of the treatment will be covered.
It will depend on the type of policy held by the patient. And basically, the higher the costs of the cover, the more items are covered regardless of a financial limit. The lower or budget type cover may set a financial limit on how much can be paid out under the policy or, for example, may exclude consultation fees.
Is this relevant to the consultant surgeon?
In this writer’s view whilst it may impact on the consultant surgeon it will be a very sad day when a consultant even stops to consider if he/ she will treat a patient based solely on the type of insurance coverage. In such a case they would remain an MHM client.
That said what is the impact on the consultant surgeon?
For one thing, a budget type policy could easily lead to shortfalls, excess or the non-payment of consultation fees. This, in turn, in order to avoid a financial loss on his part, will lead to a requirement for the consultant to have such amounts collected from the patient.
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Most consultants are concerned, quite rightly, with how and why a patient has chosen to see them. Before asking the question why and how does a patient choose you as a consultant an early question is asked. Why have the patients taken out private medical insurance originally?
There are three major reasons.
Empirical research on the patients of MHM clients indicates whilst most private healthcare originates via a patient’s employer, even if the insurance is paid for privately, the number one reason for holding private healthcare cover is to avoid and cut short NHS waiting lists. This is the primary reason patients have private medical insurance cover.
But whilst private health cover gives a prompt access to treatment, the second reason for having private healthcare insurance is that it offers the additional benefit of when and where the patient may be treated. Aligned to this is the ability to recover, if surgery is necessary, in a private suite, which is more convenient to both the patient and his/her family.
Thirdly, and finally, private insurance offers a choice of a consultant to the patient.
Before considering why a patient should choose to see you as a consultant, it is equally useful to consider why the patient has private medical insurance in the first place.
The major reasons patients choose to take out or receive private medical insurance are, in the main, three:
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August is the silly season with people on holiday at various times throughout the month, as we all know. Returning in September it’s catch up time!
Assume your practice secretary is on leave for the last two weeks of August, therefore, all clinic lists have to be invoiced for the last two weeks of that month and thus a particular patient’s follow up appointment invoiced.
Standard practice in such a case is to check if the initial consultation has been paid.
In this example, the initial consultation had not even been invoiced as the clinic list for that day hadn’t been supplied and audited against the invoice register! If it had it would have been discovered that none of the consultations for the day had been invoiced.
And the total clinic was worth £1,450.
Thus whilst shortfalls/excess/non-payment may cost the consultant money, not raising an invoice is 100% guaranteed to lead to non-payment.
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There was a story on the BBC website regarding the safe use of mobile phones when driving.
Apparently, there are still those who hold the phone to their ears. There are those who read emails and text too. It’s all to do, or so it’s claimed, with the concept of working over and above that which is normally required.
Maybe I’m the exception to the rule as I have a wonderful and 100% safe way of using a phone whilst driving.
It all goes back to a Friday afternoon on the M25 last year when I was happily talking away on my Bluetooth kit to a friend of mine. And totally failed to realise I’d just driven past the junction for the M40. Since then I’ve had the phone switched off. No more beeps as an email arrives and no more distractions.
But I hear you say, I could possibly miss an important call? Yes, I could. For at least two hours i.e. in between motorway service stations anyway. Will the world end in those 2 hours? Doubtful.
Modern technology is great. You can be in constant communication with anyone, anywhere in the world. I have clients who email me at obscure times of the day. As consultant surgeons, they don’t exactly work 9-5 hours. I email them at odd times too. But seldom does an email require an immediate response either from them or to them. Of course, it requires a response at some point but it does not require a knee-jerk reaction. Most likely the best thing to do is not respond immediately anyway. Much better to understand the issue and then give a measured and fully considered response for the client’s benefit. Much better for my clients and much better for my business.
My clients are the single most important thing in my business. They require total commitment and a consistently high level of service. Just the same as any business.
Yet this concept of working over and above normal requirements to satisfy a client persists. I’m not against working really long hours. I’m absolutely not against providing an extremely high level of service. I do it. My clients provide an incredibly high level of care to their patients i.e. they do it too.
What I am against is this notion that working really long hours and answering the phone or emails proves dedication to a task. I suggest in reality, long hours may prove counterproductive sometimes or in the case of using a phone/answering emails etc whilst driving proves there is always an accident just waiting to happen or a motorway junction to miss.
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I was literally 70% through billing for a client’s clinic lists from last Friday. Eight separate patients and a mixture of initial and follow up consultations.
All was going well until I noticed the details of one of the patients on the clinic list were incomplete. The only solution was to speak to the patient’s insurance company. I need accurate data to bill effectively and efficiently. So I called the insurance company but like many when you call them you join a queue and have to wait.
So far I’ve been on hold for 16 mins.
Yet this problem could have been so easily avoided if the correct details had been taken down and checked. The problem was the policy number had not been recorded, as it should be.
Just got through and it transpires the date of birth is also wrong. The patient was born a year earlier than stated on the clinic list.
Three observations really:
The insurance company may well clear and pay the invoice even if the details are incomplete and/or incorrect, there again they may not.
If the details had been checked originally before the clinic list had been produced, none of this would have been necessary and the invoice would have been processed for payment much quicker.
Finally, if your med-sec is handling your billing, whilst he/she is on the phone for 20 mins to an insurance company she’s not actually talking to patients and booking them in or typing your letters. Indeed patients can’t call her because she’s on the phone sorting out issues such as the above.
So it’s taken around 20 mins to sort this one single issue and that is what can take up so much time!
How many times have I said most clearly: INVOICE RIGHT = GET PAID RIGHT??
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One MHM client provides expert reports for actions that are publicly funded i.e. invoices are passed to the Legal Services Commission.
Consider there are FOUR parties to an action, all of whom are publicly funded. The first item to establish is how much is chargeable and at what rate together with what is NOT chargeable. Earlier this year (for example) the hourly rate was reduced so actions commenced before a change date becomes chargeable at one rate, those after at a lower rate. For the purposes of this example, assume the current rate is £125 per hour. So, the expert took:
4 hours to read the report 3 hours to dictate it 1 hour to proof read and amend if necessary.
Therefore it took a total of 8 hours – 8 hours @ £125 per hour = £1,000.
But there are FOUR parties to the action and therefore four completely separate invoices need to be raised for £250 each. It is not advisable to send one invoice to the lead party for two reasons: (1) you are expecting them to collect your money for you (2) you are relinquishing control of who precisely owes you your money and what’s happening with it.
That said, your invoice MUST show the number of hours for EACH separate item i.e. reading, writing etc. If an invoice just stating £250 is raised it WILL be rejected.
Consider the issue of a Court Appearance.
The number of hours at Court is also chargeable at £125 per hour. Time taken in traveling to Court is also chargeable but only at £40 per hour. Mileage is another area that causes confusion. MHM overcomes this easily. Take the postcode of the expert’s start point and the postcode of the destination and look them up on www.theaa.com or another route finder website. It doesn’t really matter which.
What is important is that the distance is based on a fixed source. This is infinitely better than just saying 90 miles for example. If the allowance per mile is, say, 40 pence, then 40 times 90 = £36.00.
Hopefully, the above gives and an indication of how to tackle how to invoice for a publicly funded report.
However… Do not consider instead of stating 4 hours to read a report, put a claim in for 7 hours in order to increase your fee because the Legal Services Commission guys are seriously switched on. They know only too well, how long a “standard” report takes to prepare. There may well be nonetheless a perfectly genuine reason why the report took longer and therefore you should say so.
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Most consultants, and certainly when they first start a private practice consider how best they can set their fees.
In reality, however, it is not the consultant who sets his or her own fees.
It is the patient’s insurance company.
Fee setting should be viewed from two areas:
Insurance Company Fees
Self Funding Patients
Consultation fees, for example, will be agreed at the point of recognition by the medical insurance company.
Clearly, if you have 20 years post qualification experience and are one of the few consultants within your geographic area in a particular specialism, then you can command a higher fee.
In reality, most likely you not be in such a position. You will be offered consultation fees at a level set by the insurance company you are dealing with. In return, the insurance company will refer patients to you.
Surgical fees, if anything, are the easier one to deal with.
The insurance company with whom your patient is insured will always set surgical fees.
You may feel the fee is too low and therefore charge more.
Almost certainly your invoice WILL be rejected or at the very least shortfalled to the patient.
Keep sending invoices in for fees greater than that allowed by a particular insurance company and you run the risk of being de-recognized.
In the case of self-funders, however, there is nothing to stop you charging any fee you like.
Save of course if there are other consultants in your area then the fee levels they charge will influence that which you yourself charge.
Whether it is right or wrong for insurance companies to hold such power over the setting of surgical fees is for another article.
I have very firm views on it but at this point, the stark reality is that the insurance companies do hold such power.
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There are certain items that are mandatory when you call a patient’s insurance company. Such requirements are dictated by the Data Protection Act and, put simply, it’s highly unlikely without the right information you can make an enquiry regarding a patient.
In the ideal world, you will have:
The Policy Number Patients name Patient’s FULL address The POST CODE (don’t forget it) Patient’s Date of Birth Treatment date CCSD code
The pre-authorisation number is very useful too.
But what do you do if you don’t have the policy number? If you have the patients name, full address (inc the postcode!!) and date of birth you stand an extremely high chance of the insurance company telling you the policy number. Indeed often I’ve had to speak with an insurance company to obtain the policy number.
With the above to hand, it’s not an issue. Use the opportunity to confirm or obtain the pre-authorisation reference as well though.
On a parallel note, some insurance companies will only let you raise three queries per phone call with them. Some may, if they are not too busy, do more but generally speaking three is the limit.
This despite what many think, is important for if you have say 12 to do, it’s going to take time. Especially if you are on hold for 10/15 minutes BEFORE you get through to the insurance company.
So, the very best thing to do is to make sure the clinic list has absolutely everything you need in order to invoice correctly. That way, you won’t have to contact the insurance company first. Also of course, if there is an invoice query after you’ve billed the consultation/episode you will have all the data in front of you when you DO speak to the insurance company.
Without it, you will struggle.
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The normal item when I get asked to review a consultant’s invoicing process is the potential for weakness in the area of records on his/her part.
Sometimes, I’m presented with a carrier bag full of invoices, remittances, and receipts. My favourite though remains the cardboard box stuffed full of pieces of paper. That was the filing system. Close examination of the pieces of paper in the cardboard box suggested they were invoices. Many in fact did not have an invoice number on them. Indeed the majority did not actually have the word INVOICE printed on them either.
That can be a problem when I come to reconcile payments against such payments IF they’ve been paid at all. That is important because it’s difficult to contact an insurance company and discuss invoices for one individual patient if the invoice does not show a specific invoice number. In fact, the only way you can tell them apart is if the values are different and they are on different dates.
It’s always best to have a unique reference number on an invoice i.e. an invoice number and a date. And don’t forget to print the word INVOICE on it. At least that way, you stand a chance of knowing which ones have or have not been paid.
Then the hard part starts as you begin to look at what is or is not on the invoice and get a feel for what was likely to be paid anyway and what was likely to be rejected due to total lack of detail. Normally this is followed by a request to see clinic lists and the process of obtaining the right data off the clinic list for submission to the insurance company.
There is also an additional cost to not keeping accurate records. When it comes to tax time, its going to take a lot longer – and thereby cost much more – for your accountant to do the necessary computations. At worse you could end up paying too much tax.
All because records aren’t kept correctly. Please keep accurate records if only because it means you stand a much higher chance of being paid!
Please email me if you want details of the bare minimum records you should be keeping for invoicing purposes.
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This issue came up during a meeting with a consultant surgeon recently regarding the relationship between benefits and fees. More specifically how fees are accounted for against a benefits package and the possible creation of a shortfall.
Consider the total benefits payable under a patient’s insurance policy. For example, the benefits payable may be £100. Obviously, it could be considerably more as will the possible fees mentioned below.
To continue, however, against such a benefits package fees are deducted as follows:
The patient attends for an initial consultation at a cost of £20. Therefore the £20 is paid out and the total benefits figure reduces to £80. Subsequently, the patient requires a surgical episode at a cost of £50. This too is paid out and the benefits accumulator, therefore, reduces to £30. But of course, the hospital tenders their account (say £20) as does the gasman (£15). The benefits accumulator, therefore, further reduces to ZERO. Thus the benefits package is equal to the fees charged.
If the initial consultation fee is £21, the surgical episode fee £51, the hospital account £21 and the gasman’s account £16 then the total fees total = £109 against a total available benefit package of £100.
Thus, if when the fees are calculated against the benefits accumulator they exceed the total available a shortfall will be created.
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Spent some time yesterday looking at the invoicing of a consultant surgeon.
I noticed that the invoices for initial consultations going out to one particular insurance company were being charged at exactly the same fee as for follow-up consultations i.e. £125 each.
Instea,d they should be £175 for initial and £125 for a follow-up.
So… £50 multiplied by the number of errors spotted so far over the first month I’ve checked (9) = £450!
The bad news is that this has been happening for, so far as I can tell at the moment, for at least the last four months.
Potentially, £1,800 worth!
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A couple of examples recently where consultants who have tried to base their fees on the best rate available. Take the consultant who realises that PMI company Num 1 pay £300 for a procedure whereas PMI company 2 pay £400. He decrees he will charge PMI Company 1 the PMI Company 2 rate.
Great idea. Right up to the point PMI company 1 receives the invoice for the higher amount. They will decline to pay that fee. Most likely they will shortfall it. But, replies the Consultant, no problem. The patient is ultimately liable for any shortfall. I know of one consultant who even puts on his website “we use PMI Company 2 rates to calculate our fees and therefore there may be a shortfall which you will have to pay”
Yes, the patient is liable for a shortfall BUT not when the consultant is fee assured he isn’t.
Most likely a letter addressed to the Consultant will arrive sooner or later from PMI Company 1 pointing out that such “inappropriate billing” is not acceptable; carry on doing it and recognition is at risk.
It’s incredibly similar to unbundling. Continue doing it over a number of months and for sure eyebrows will be raised. Even if there is no “fee assured” status PMI Company 1 will be well aware of regular and consistent charges that are in excess of their published fee schedule.
Notwithstanding the above, of course, consultants want the best possible fee for a procedure but attempting to obtain the same by “inappropriate billing” is not the smartest way to go about it.
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Another question asked at the recent Medical Defence Union presentation.
Insurance companies use medical coding to identify and detail a medical procedure.
For example, an Orthopaedic surgeon will understand what a Multiple arthroscopic operation on the knee is. But that is an awful lot to put on an invoice every time. Plus there may be variations on such an episode. Rather put the code W8500 on the invoice which will specifically identify the episode.
Most codes can be located on the CCSD website: www.ccsd.org.uk
The Clinical Coding and Schedule Development Group (CCSD) consists of the five major healthcare insurers. Aviva, AXA-PPP, BUPA, Vitality and Simply Health. Its purpose is to maintain a common standard of procedure codes. Consequently, CCSD publishes a Schedule of codes which reflect current medical practice.
However, be warned. Whilst the example above of W8500 will be recognized, a CCSD does not publish a suggested rate of remuneration. The rate payable for each code is up to the individual insurance company concerned. As a result, the surgeon has to check with the patient’s insurance company.
A CCSD code is imperative IF a surgical episode is required. The patient will need to quote the code to his or her insurance company when pre-authorisation is being requested anyway.
Thus when an invoice is sent to the insurance company for your fees, the code should appear on the invoice. It will reconcile to that expected by the insurance company.
If alternatively, you do NOT use CCSD codes payment will be substantially delayed if made at all!
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I very recently wrote about this issue and have been asked if the increase was just a blip and possibly “one of those odd things”???
Therefore auditing the work of the same consultant surgeon I wrote about in mid-February:
Week commencing Monday, March 24th and ending Friday, March 28th he saw 18 patients. Total invoices sent to various insurance companies came to £2,200.
The insurance companies subsequently advised 21% or £460 would be subject to shortfall/excess. February the same number was 23% or £575.
Therefore the consultant is now required to collect £460 from the March patients with the balance of £1,740 being paid by the insurance companies.
Some consultation fees were declined completely. Others were only partially paid with the balance deemed “shortfall” or ‘excess” i.e. the £460 is due from the patient(s). If this week is taken as a norm and multiplied by 48 (assume the consultant has 4 weeks holiday each year) –
He will undertake just under £106,000 worth of outpatient consultations throughout 2014.
He will be left with around £22,000 worth of shortfall and excess fees to collect.
Even if we apply the same criteria as employed previously and assume only 50% of shortfalls/excess will remain unpaid. Whilst that’s still £11,000 even though it has dropped from the original Feb calculation which projected £13,000 it hasn’t moved that much.
Incidentally of the original £575 worth of excess/shortfalls for Feb only £50 remains unpaid.
But now is the time to start thinking about what is happening to your practice because £11,000 is one HUGE perspective more so as surgical fees continue to be reduced by the insurance companies.
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